Clinical Documentation Specialist - RN (3 Vacancies)

Jackson Hosptial & Clinic Montgomery , AL 36101

Posted 2 months ago

SCHEDULE: Full-Time; Monday - Friday; Days


The RN Clinical Documentation Specialist will facilitate improvement in the overall quality, completeness, and accuracy of clinical documentation. Through concurrent interaction with physicians, case managers, coders and other health care team members, the RN Clinical Documentation Specialist, will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions, and diagnosis for all inpatients.

Serving as a resource to all members of the health care team on documentation guidelines, this position will provide guidance and support, as well as assisting with education and training related to improving clinical documentation. This position will actively participate in educating appropriate hospital and medical staff about the changes associated with transitioning to ICD-10


Education: Holds a current Registered Nurse License. Prior experience in case management, utilization review, clinical documentation improvement, and/or coding accuracy preferred.

Experience: Minimum of five years experience in an acute adult in-patient clinical role for RNs and LPNs with demonstrated critical thinking skills , process improvement in an acute care facility preferred or equivalent experience.

Coding skills with experience in ICD-9-CM, knowledge of CMS Inpatient Prospective Payment System, and working knowledge of AHA Coding Clinic, preferred. Bachelors degree in nursing may be substituted for two years of the required work experience. Must have strong computer skills and the ability to type on a keyboard.

Prefer experience with Microsoft Office products including Excel. Certified Clinical Documentation Improvement Specialist (CCDS) or Certified Documentation Improvement CDI Practitioner preferred. Excellent demonstrated oral, written and communication skills.

Proven communication skills in dealing with multidisciplinary clinical and operations teams including physicians. Current working knowledge of one or more of the following: Medical /Surgical Nursing, Critical Care, Care and Case Management (Resource Utilization), Surgical Services, Accreditation and Regulatory Compliance, Core Measures and Public Reporting of Hospital Quality Data.

Experience in development of reference based continuing educational programs using Adult Learning Principles. Must be self-motivated and have the ability to work within the established policies, procedures and practices prescribed by the facility, corporation and the immediate supervisor. Must be able to work independently and as a team member.

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Clinical Documentation Specialist - RN (3 Vacancies)

Jackson Hosptial & Clinic